Case Study

From Conflict to Alliance: A road map for family interventions

By Thomas Sexton

Sarah’s arrest came as a complete shock to her parents, Edward and Ellen. True, the 15-year-old had experienced difficulties for many years. Adopted when she was 2, she showed oppositional behaviors when she was 6, was placed in a special section at her school for kids with behavioral problems when she was 10, and had a long history of different counselors and psychologists. Since starting high school, she’d begun running with the wrong crowd and started smoking dope. Still, with all the therapy through the years focused on helping her learn to control her anger, Edward and Ellen thought the worst was behind them. They certainly didn’t expect a cop at the door saying that their daughter had been caught riding in a car with a group of teens who’d robbed an electronics store. This was the “last straw” for her parents, who were now considering whether to send her to a residential treatment facility.

When Sarah and her parents came to the first session, they were tense and upset. My first question—“Can you tell me what goes on between the three of you?”—was immediately met with an angry outburst from Sarah’s father, a teacher at the local high school. “I’m done with this! You need to talk with her; we’ve been through enough!” he yelled. Sarah’s mother, said, “Ed, stop it! I am so tired of all this.”

Sarah immediately stood up and yelled back, “This is exactly why I didn’t want to come here today! I’m not going to say anything!” before sitting down with a sullen look on her face. Meanwhile, Sarah’s mom, Ellen, sat silent, distant, and detached.

Edward stood, moved toward Sarah, and in a quiet, but seething voice said, “We’re done. I see no way out—you’re out.” He turned to me and in the same subdued, angry tone said, “We’ve already talked with a residential treatment program, and we decided that if this didn’t work, we’d send her. We want your help in deciding which one is best.”

Despite long experience working with families, as well as researching and writing about working with angry families, I still find myself surprised and a little scared by explosive outbursts like this. In the first moments with this family, I felt caught between Edward’s request, Sarah’s desire to be heard, and the strong feelings in the room.

Like many therapists, I want to take action immediately to calm volatile emotions and try to make a difference. But what could I do here?

Finding a Clinical Road Map

In training, I learned all the psychotherapy theories, but in actual practice, theory rarely helped me know what action to take in any given moment, particularly when family members are openly raging at each other. Over the years, I’ve found that I’ve needed a solid, research-backed clinical model, which would guide me in sessions and keep me grounded during conflicted family interactions, and be flexible enough to allow me to draw on my intuition, creativity, and sense of the client.

The one I use, based on 30 years of research on the most effective interventions with delinquent and violent juveniles and their families, is Functional Family Therapy (FFT). Like other models, it provides a framework for conceptualizing the case, focusing attention on significant aspects of the client’s dilemma, relational family patterns, and history, and more important, a kind of “clinical GPS” system. It not only shows a way through rough, unmarked territory, but allows you to update decision points and recalibrate the therapy to fit changing circumstances and unexpected developments.

The core notion of FFT is that there’s a beginning, a middle, and an end to the therapeutic change process, which correlates with three distinctly defined phases of treatment: engagement/motivation, behavior change, and generalization. Each has specific goals and requires specific therapeutic skills.

I knew I needed to act quickly to get this family engaged and motivated before the session ran away without me. The clinical GPS that FFT provides told me that the first thing I needed to do to achieve the primary goal of phase 1—engagement and motivation—was to use the event in the room to reduce negativity and blame, and create a family focus. Also, I had to do it in a way that “matched” the family’s style.